Failure to Timely Report Suspected Neglect and Delayed Emergency Response
Penalty
Summary
The facility failed to ensure that an alleged violation involving resident neglect was reported immediately, as required by state law and facility policy. A resident, who was admitted with a full code status, was found unresponsive by a CNA during a shift. The LPN on duty assessed the resident, found no pulse or respirations, verified the code status, and initiated CPR. However, the LPN did not call 911 or initiate a Code Blue, which was contrary to the facility's protocol. The LPN also pronounced the resident's death, which was outside his scope of practice, and did not provide a written statement regarding the event at the time. The CNA involved was not asked to provide a written statement until the date of the survey. The incident was not reported to the State Survey Agency or other appropriate authorities within the required two-hour timeframe. Instead, the event was reported five days after it occurred, following a determination by the corporate office that the incident was indeed reportable. Initial internal discussions among the Administrator, DHS, and corporate personnel led to the incorrect conclusion that the event was not reportable, based in part on undocumented statements that the resident was already deceased when found. There was no documentation or witness statement to support this claim at the time of the initial review. Interviews with staff revealed confusion and lack of adherence to the facility's abuse prevention and reporting policy. The LPN did not follow the established protocol for emergency response and reporting, and the facility's leadership did not immediately recognize the event as a reportable incident. The delay in reporting, lack of timely documentation, and failure to obtain witness statements contributed to the deficiency identified by surveyors.